reimbursement scope of medical insurance for urban residents in Xinzheng

I. reimbursement process of medical insurance for residents

1. Residents seek medical treatment in local designated institutions, and the insured residents go to the hospital medical insurance window with medical insurance cards and medical insurance prescriptions for settlement. Those who belong to the medical insurance scope are reimbursed in proportion, and the insured residents only need to pay the rest.

reimbursement rate: 6% at township level and 5% at county level, with the highest annual payment of 12 yuan.

2. When hospitalized, the insured residents go to the hospital with medical insurance cards, which belong to the part paid by the overall fund, and are kept by the designated medical institutions. The municipal medical insurance center and the designated medical institutions settle accounts regularly, and the part that individuals should bear is paid by individuals in cash.

3. Instructions for outward medical treatment: Insured residents need to go to the municipal hospital to issue a referral approval form, and go to the residents' medical insurance department for referral approval. Only after approval can they be transferred to the hospital, and the hospitalization expenses will be paid by individuals first; Insured residents carry referral approval form, discharge certificate, diagnosis certificate, invoice, general list of expenses and copy of medical records to the residents' medical insurance department for reimbursement after discharge; After the staff of the residents' medical insurance department review the reimbursement, the insured residents can go to the financial office to receive the reimbursement expenses with the relevant documents.

II. Basis for performing functions and powers (responsibilities)

Scope and standard of reimbursement for urban residents' basic medical insurance

III. Undertaking department and department head

Undertaking department: Resident Medical Insurance Department

Responsible person: Lin Junhong (chief)

IV. Processing time limit

Insured residents carry referral approval form, discharge certificate and diagnosis after discharge.

V. Supervisory organ

Supervisory organ: xinzheng city Human Resources and Social Security Bureau Committee

Tel: 371-6326119

xinzheng city residents' medical insurance reimbursement process

1. See a doctor at a designated medical institution in xinzheng city

1. See a doctor at an outpatient clinic

Insured residents arrive with a medical insurance card and a medical insurance prescription. The specific reimbursement ratio is: township hospitals 6%; County hospitals 5%. The maximum payment per person per year is 12 yuan.

2. Prescribed disease reimbursement for residents' medical insurance outpatient service

If the insured residents belong to the three prescribed disease ranges of "radiotherapy and chemotherapy for malignant tumors, dialysis treatment for chronic renal insufficiency, and anti-rejection treatment for allogeneic organ transplantation", they can apply for reimbursement for prescribed diseases in outpatient service according to the needs of their illness.

specific reimbursement method: 6% of outpatient medical expenses incurred by insured residents for three specified diseases shall be paid by the overall fund, and quota management shall be implemented. Among them, the maximum monthly payment for malignant tumors is 5 yuan; The maximum monthly payment for dialysis treatment of chronic renal insufficiency is 1 yuan; The maximum monthly payment for organ transplantation is 2 yuan -1 year after operation, 14 yuan 1-3 years after operation, and more than 3 years in 1 yuan.

3. Hospitalization

Insured residents are hospitalized in designated medical institutions with cards for medical treatment, which belongs to the part paid by the overall fund. The designated hospitals keep accounts, and the municipal medical insurance center and the designated medical institutions settle accounts regularly, and individuals only need to pay the remaining expenses. Those who belong to the fertility part can be reimbursed as long as they meet the national family planning policy. When they are hospitalized, they will be paid in advance. After discharge, they will be reimbursed by the residents' medical insurance department with copies of medical records, settlement invoices, consumption summary lists, discharge certificates, diagnosis certificates, copies of medical insurance cards, copies of original birth certificates and copies of identity cards of both parents of newborns.

Second, those who seek medical treatment outside xinzheng city shall be reimbursed according to the following procedures

1. Insured residents shall issue a referral approval form to the municipal hospital and go to the residents' medical insurance department for examination and approval. Only after examination and approval can they be transferred to other places for medical treatment, and the hospitalization expenses shall be paid by individuals first.

2. After discharge, the insured residents bring the referral approval form, discharge certificate, diagnosis certificate, settlement invoice, expense summary list, medical record copy and medical insurance card copy to the residents' medical insurance department for reimbursement.

3. Residents' medical insurance staff shall review the hospitalization expenses of insured residents according to the medical insurance policy. The audit results are forwarded to the medical insurance finance department.

4. The financial personnel will transfer the reimbursement amount to the medical insurance co-branded card of the insured residents; Residents without cards will receive reimbursement from the medical insurance finance office within the specified time with relevant documents.

III. Reimbursement proportion and payment limit

1. If the insured residents seek medical treatment in designated hospitals at the township level, the deductible line is 2 yuan, and the reimbursement proportion for those under 18 years old is 8%, and that for those over 18 years old is 7%.

2. For insured residents seeking medical treatment in county-level hospitals, the deductible line is 3 yuan, and the reimbursement rate for those under 18 years old is 75%, and that for those over 18 years old is 65%.

3. For insured residents who seek medical treatment in municipal designated hospitals, the deductible line is 5 yuan, and the reimbursement rate for those under 18 years old is 7%, and that for those over 18 years old is 6%.

4. The maximum annual payment for basic medical insurance is 43, yuan per person, and the maximum annual payment for supplementary medical insurance is 6, yuan per person, totaling 13, yuan per person.